XVII Harry Benjamin International Gender Dysphoria Association Symposium
31 October - 4 November 2001, Galveston, Texas, U.S.A.

HIV Risk Behaviors among Male to Female Transgenders of Color

KEATLEY, JOANNE U.S.A.

Examines the context surrounding HIV risk, drug use, and mental health needs among Male-to-Female (MFT) transgenders of color in San Francisco. Forty-eight MTF transgenders participated in ethnic-specific focus groups to discuss the psychological, cultural, and social context for commercial sex, drug use, and hormone injection. To be eligible for the study, participants had to be 18 years or older, identify themselves as MTF transgender (either pre-operative or post-operative status), and have engaged in commercial sex work. Within the sample, there were 16 African Americans, 15 Asian Pacific Islanders, 12 Latinas, and 5 other/mixed ethnicities. We conducted two focus groups with each ethnic group as well as a multiethnic pilot group, and each group had between 5 and 10 participants. Discussions were audiotaped and later transcribed. Focus groups with Latino participants were transcribed first into Spanish, then translated into English. Members of our research team analyzed discussion transcripts, and identified recurring themes that emerged from the discussions. These themes included psychological needs and mental health, commercial sex work, drug use, relationships and social support, hormones and gender confirmation, and community resources and services.

Psychological needs and mental health were the most recurring themes across focus groups. Participants reported psychological issues from each childhood to adolescence to current daily life. These issues appeared to underlie current risky behaviors such as commercial sex work and drug use. These issues included trauma resulting from childhood abuse: feelings of isolation and rejection from the larger society and from significant others; unhealthy coping mechanisms such as drug use and sex addiction; self-esteem conflict due to negative images of transgenders throughout the media and society; and fatalistic attitudes toward life.

Commercial sex work provided a common means for economic survival for participants. Although only half of the participants were currently sex workers, most had a history of exchanging sex for money or drugs. Common experiences emerged from discussion, including reports of customers offering more money if sex workers agreed not to use condoms; commercial sex work being perceived as a rite of passage for young transgenders; violence from sex customers; feelings of depression and immorality due to sex work; and riskier sex with customers when feeling depressed or under economic pressure. Interestingly, however, participants reported engaging in more unprotected sex with primary partners than with commercial sex customers.

Drug use was a common experience in the community sample. The most common drugs used were crack, speed, and marijuana. Drugs provided a way of coping with adverse life conditions. Drug use also increased the amount of sexual risk taking. Common drug issues included inadequate drug treatment or harm-reduction programs that are sensitive to transgender issues; drug use as a form of escape and comfort; drug use with sexual partners; engaging in sex work to support drug habits; and histories of drug use starting as early as adolescence.

Relationships and social support were crucial to the well-being of participants, because loneliness and alienation were common in their lives. Family and romantic relationships provided the most satisfying feelings of connection, but participants also relied on close friends, support groups, and therapists. Many of the participants reported having supportive parents and family, and family support was associated with more self-esteem. Many participants found support from older transgender mentors who assisted in their gender development process. Many participants were seeking a primary romantic relationship; those who were in relationships expressed anxiety about remaining with their partner. Abuse from private partners was common, but participants were willing to endure abuse to keep their relationships going.

Hormones were used by almost all participants to maintain appearance and sustain their gender confirmation process. Use of underground ("black market") hormones was the norm; clinics typically distributed hormone pills, but the participants preferred hormone shots because of more satisfying physical effects. However, sharing hormone needles was not commonly reported in this sample. Participants remarked about the psychological effects of hormones, including depression, mood swings, and violence. According to participants, medical services are often uninformed about hormones and surgery procedures.

Community resources and services are vital to advancing the needs of the transgender community. Participants reported, however, that existing resources and services are often inadequate. Resources and services are essential for diminishing HIV risk and improving overall health in the transgender community. These include job training programs, better access to health care, health providers who are informed about transgender needs, housing and roommate services, and more visible transgender staff at social service agencies.

We derive several recommendations from these qualitative findings. Psychological services and interventions designed specifically for transgenders can reduce risky behaviors that lead to violence, HIV infection, and drug use. Transgender-specific drug treatment programs are necessary to alleviate the impact of substance abuse in the transgender community. Community services for transgenders should consider the diversity within the transgender community, such as differences in clients’ age, ethnicity, and occupation. Health care and service provers need increased education about diverse health and psychological needs for transgenders. Finally, the transgender community can empower itself by uniting across ethnic and age barriers, and advocating for their health, social, and economic needs.